Patients should be good medical candidates for major surgery.

Preoperative planning requires a thorough history of previous abdominal surgeries.

If performing a metastasectomy, there should be a thorough evaluation of extrahepatic disease. The presence of extrahepatic disease should be considered in conjunction with the tumor type and extent of resection to determine if the patient will benefit from surgical intervention involving the liver or extrahepatic sites.

Episodes of jaundice, hepatitis exposure, alcohol, illicit drug abuse, and treatment with chemotherapy should be elicited to ascertain the health of the liver parenchyma.

A complete viral hepatitis panel should be obtained as part of screening surgical candidates.

Liver function can be assessed by the Child-Pugh classification and/or the Model for End-Stage Liver Disease (MELD). Neither metric has been definitively shown to be superior in determining a patient’s ability to tolerate surgery.²

Multiphase, contrast-enhanced cross-sectional imaging with either computed tomography (CT) or magnetic resonance imaging (MRI) is necessary for planning surgery. Both imaging modalities are of similar sensitivity and may often be used interchangeably or in combination to better define certain pathologic processes.

In a normal, healthy liver, a future (postresection) hepatic remnant composed of at least two contiguous segments with adequate inflow and outflow and measuring 25% of the complete liver volume is sufficient functional liver to allow for full hepatic recovery. However, in a damaged or cirrhotic liver, a remnant of greater than 40% is often recommended, although the percentage of viable remnant liver may need to be greater, depending on the amount of damage/dysfunction of the liver. Segmental hepatic resections rarely induce hepatic insufficiency unless the remnant liver is severely diseased.

Concern for significant hepatic dysfunction should be investigated by objective testing of the liver. Transjugular measurement of the portal pressure gradient (normal <5 to 8 mmHg), routine serum liver function tests, and biopsy (to evaluate steatosis or cirrhosis) are the most common modalities to evaluate the extent of hepatic disease.

In Asia, indocyanine green clearance testing is often performed to quantify liver health. This is rarely performed in the United States.

In patients with evidence of decompensated cirrhosis (Child’s B and C) and pathologic conditions that have demonstrated benefit from transplantation (hepatocellular cancer, neuroendocrine malignancies, and some hilar cholangiocarcinomas), surgeons should consider a referral for transplantation.

The indications for hepatectomy include diagnostic uncertainty, symptomatic benign lesions, and malignancy (Table 1).

The strongest evidence for hepatic metastasectomy shows that R0 resection prolongs survival and is potentially curative for colorectal carcinomas and neuroendocrine tumors.